By Dr. Melissa Baudo Marchetti, PT, DPT, SCS, MTC
Injuries to the lower leg are common in tennis because of the high demand of the sport and the repetitive, quick movements required. “Tennis leg” is an incomplete tear or rupture of the calf muscle in the lower leg. The calf muscles include the superficial gastrocnemius — the larger of the lower leg muscles — and the soleus — the smaller, deeper muscle that runs under the gastrocnemius. The Achilles tendon connects the gastrocnemius and soleus muscles to the heel bone.
“Tennis leg” commonly occurs in players who range in age from 35 to 50 years old. This muscle injury may occur as a result of a sudden contraction of the calf muscles, for instance during a sprint or acceleration to reach a shot, a sudden change of direction or during push-off in the service motion. Tennis players often report a sudden sharp or burning pain in the leg, sometimes accompanied by an audible “pop” and a feeling like they have been kicked in the leg. In most cases, the player is unable to continue play because of the severe pain, which makes walking very difficult.
When a muscle has been strained, it is stretched beyond its allowable length and tears. If you experience a calf strain or “tennis leg,” take immediate action. Fast and optimal first aid is critical for a speedy recovery. In severe cases, or if in doubt, consult your orthopedist and/or physical therapist for further evaluation. If you are having difficulty walking, most orthopedists will put you in a walking boot so your leg can rest and heal while still allowing you to walk and function. Physical therapists have a myriad of techniques to help decrease the pain and swelling and to restore motion, strength and power. Depending on the severity of the calf strain, recovery may take between four and six weeks.
Rest. If walking is painful and difficult, get a pair of crutches so you don’t have to bear weight on the injured muscle. It is ideal to use crutches as long as you are still limping. As the pain subsides, you may start putting weight on the foot. Once you can walk without a limp, you can ditch the crutches.
Ice. You can apply ice or a cold pack directly to the painful area for 20 minutes or submerge your lower leg in a bucket of cold water and ice for 10 minutes. Repeat this several times a day. Do not place an ice pack on the bare skin. Place a towel between the skin and the ice pack to avoid a cold burn.
Compression. Apply a compression wrap to the lower leg starting from the foot and wrapping up to the knee. This is important as it compresses the small vessels in the calf and limits bleeding and prevents blood and fluid from accumulating in the foot and ankle.
Elevate. Try to elevate the lower leg the first few days following the injury to minimize swelling in the foot and ankle.
The Road to Recovery
It is ideal to seek care from a physical therapist to guide you through the rehabilitation process. Here’s what you can expect during your rehabilitation:
Manual Therapy. Calf muscles are often very stiff and sore following the initial injury. Physical therapists implement soft tissue mobilization techniques to restore the normal length and mobility in the injured tissue, so it is important to not skip this step.
Heel Lifts. Inserting a heel lift with shock absorption in both shoes for one to two weeks may help ease the load on the calf muscles during walking.
Cardio Training. Swimming or gentle cycling for 30 minutes every day increases the blood flow to the calf muscles and enhances recovery. This may be challenging at the beginning of rehab, so let your physical therapist guide you.
Stretching. Calf muscles may still be painful early on, so be gentle when stretching. Step forward with the unaffected leg, keeping the heel of the back leg on the floor. The knee of the affected leg is kept straight. Shift your body weight forward and press the heel of the back leg firmly into the floor. You will feel a stretch in the upper calf region of the back leg. You can also stretch the deeper, shorter muscle in the calf. Start from the same position as described above, but now bend the knee of the back leg while keeping the heel on the floor. The stretch is felt lower in the calf. Hold each stretch for 15-20 seconds (no bouncing), followed by 10-20 seconds of rest. Repeat three times.
Strengthening. As soon as you can walk without pain, you will begin the strengthening phase of rehab. Heel raises are a good start to strengthening the calf muscles. Slowly rise onto your toes and hold this position for 5-10 seconds. Then, slowly return to the starting position. Perform this exercise with both feet at the same time. You will progress this to heel raises off a step and on one leg.
Plyometric Training. Also known as “jump training” or “plyos,” these are exercises in which muscles exert maximum force in short intervals of time, with the goal of increasing power (speed and strength).
Agility Drills. To ensure that you are ready to return to tennis, perform agility drills to work on your lateral movements, balance, speed and coordination.
Return to Play
A gradual return to tennis is recommended. Perform a good dynamic warm-up before hitting so that your legs are fully warmed up before playing. You can start hitting either against the practice wall or with mini-tennis and gradually increase the distance from the wall or your opponent on the court. Make sure you position yourself well for the ball by taking small steps. Start with your groundstrokes, then progress to volleys, overheads and serves. As long as you don’t have any pain and you can smash the ball with good footwork, you are ready to start playing points, games and a practice match. Once you have played practice matches for two weeks in succession without problems, you can return to competition.
You can reduce your risk for “tennis leg” by paying attention to the following points:
Prepare. Sufficiently warm up before playing; it is critical for injury prevention. Get to the court early to perform a dynamic warm-up. A 5- to 7-minute dynamic warm-up is ideal within 15 minutes of match time. This includes movements to help lengthen your muscles to prepare for tennis and increase heart rate and body temperature so that the body is warm, which may help decrease a risk for injury. Once the dynamic warm-up is complete, you may grab your racquet and start hitting.
Recover. Immediately following your match, stay on the court to stretch your arms and legs. A cool down helps keep the muscles from being stiff or sore the next day. Stretching helps maintain flexibility and joint mobility. Hold each stretch for about 30 seconds. Cool-down stretching should be done within 30 minutes of coming off the court, so do this before you shower and change clothes.
Roll it out. Foam rolling is a great way to stretch and massage muscles and fascia after play. It is recommend to combine this with stretching. Roll each muscle for about 30 seconds.
Repair. At the end of the day, take a warm bath with 1-2 cups of Epsom salt for about 15 minutes. The magnesium sulphate in Epsom salt is soothing for sore, tight and tired muscles and diminishes pain and muscle tension promoting more restful sleep.
Protect. If you have experienced a calf muscle strain or “tennis leg,” consider applying a compression sleeve around the lower leg. During the cool weather months, adapt your clothing to the weather conditions. It may be a good idea to wear pants, running tights or compression gear to keep your legs warm. Well-warmed muscles are better able to withstand pulling and traction forces than cold muscles.
Massage. Every few weeks, consider investing in a deep tissue or sports massage to help improve circulation and repair tired, sore, tight muscles.
Cross train. Cycling, running, Pilates and yoga are great ways to cross train for tennis, which build strength and flexibility and will help reduce your risk of muscle strains and tears.
“Tennis leg” is a common injury seen in recreational tennis players that is a result of repetitive overload and lack of preparation and recovery. You will need to take time off tennis to rehab your injury. Even mild strain will benefit from physical therapy sessions and may ensure that all mobility, flexibility and power return to the injured muscle. Seek immediate care from a physical therapist to take advantage of the many treatment interventions available and to learn the prevention strategies necessary to get you back on the court safely and quickly.
Dr. Melissa Baudo Marchetti is a board-certified sports clinical specialist at One on One Physical Therapy. She teaches a sports physical therapy course and assists in teaching orthopedics within the Division of Physical Therapy at Emory University. Learn more by visiting onetherapy.com.